The road to value-based care runs through social services

A partnership with a service provider that integrates social services into healthcare is helping San Francisco Bay area-based Contra Costa Regional Medical Center and Health Centers reinvent care delivery.

The Contra Costa healthcare system partners with Health Leads to direct patients to resources that affect health, including food and housing, according to an article in NEJM Catalyst. In an interview, hospital CEO Anna Roth, R.N., talked about how the program works for her hospital system.

Roth talked about a recent meeting in which many providers from a large clinic "choked up" when they learned that the top need met by the hospital's Health Leads advocates was food.

"Many have worked for decades in the center of this safety net with no way to meet that kind of need," she said, adding, "That is how you build resilience: by surrounding providers with tools that help them meet the needs of people they've dedicated their lives to serving."

While most care is still paid for through fee-for-service programs, Contra Costa also receives funding through federal demonstration projects and associated state waivers, Roth said.

"We all dream of a fully reformed healthcare system and the payment reform that goes along with it, but that will take a while," she said.

She added that healthcare organizations don't have to try to do everything themselves.

"It is time we look beyond the four walls of our institutions and see how we can partner with those who have already mastered things like housing and employment," she said. If those networks and organizations need help, she said, "maybe the role we can play is to be strong partners for them so they can strengthen themselves."

The Centers for Medicare & Medicaid Services (CMS) is spending up to $147 million in grant money starting this fall to fund similar partnerships under a new Accountable Health Communities (AHC) model that will screen Medicare and Medicaid recipients for health-related social needs. Bridge organizations will conduct the screenings and refer patients to clinical and community services.

Hospital-community partnerships have a better chance of success if the partnership's goals are clear and transparent, start with one or more "anchor institutions" dedicated to the mission and supporting it financially, and if a broad range of public and private partners engage with the partnership over time, FierceHealthcare previously reported.